The art and science of non-invasive ventilation

Non-invasive ventilation (NIV) is one of the most relevant recent advances in the management of patients with severe acute respiratory failure (ARF). NIV is considered a standard of care for the management of hypercapnic ARF in patients with acute exacerbation of chronic obstructive pul- monary disease. With an appropriate selection of patients, NIV can reduce the need for invasive me- chanical ventilation, mortality and length of stay. Patients with severe hypoxemic ARF have in gen- eral a lower likelihood to need tracheal intubation when NIV as a support for ARF is added to the standard medical treatment. However, the effects of NIV on mortality are less evident, and the het- erogeneity of the different published studies sug- gests that the efficacy may be different among dif- ferent populations. The optimal time for intubation after NIV failure remains a challenging issue due to increasing evidences on the relationship be- tween delayed intubation and excess mortality in these populations. In intubated patients with pre- existing lung disease, the use of NIV in order to advance extubation during difficult and prolonged weaning can result in reduced periods of endotra- cheal intubation, complication rates and improved survival. Moreover, NIV immediately after extuba- tion is effective in avoiding respiratory failure after extubation and improving survival in patients at risk for this complication, particularly those with chronic respiratory disorders, cardiac co-morbidi- ty, and hypercapnic respiratory failure. KEY WORDS